I wrote a piece on tobacco and the role of harm reduction. I’ve written on this before (here is one of my old Northern Doctor posts on the subject) and it seems to stir up some good discussion. I know NICE are consulting on this – I think it could become a hot topic in the next year or two. So, I thought it might provoke a little controversy but I’ve not heard a peep. Interestingly, I did get an email from Big Tobacco asking me if I would meet them to discuss my work. I haven’t followed up on that.

I also wrote a book review for Margaret McCartney’s The Patient Paradox. I’m sure you’ve read it already. You can buy it from Pinter & Martin here. I’ve just noticed that P&M are using a quote from my review.

The arguments are measured and well-referenced; the conclusions are distressing… Read this book. But don’t expect to be able to practice medicine in the same way again.

I hope that that this post will form part of a regular series of BJGP blogposts. My aim is to post at least once per issue with a brief summary of a few articles from that month’s BJGP. I’ll prioritise clinical topics and particularly articles where I think there is a sporting chance they could actually change one’s practice.

The overall theme of the issue is communication and the editorial Calling time on the 10-minute consultation draws together some of the strands from the papers published. Ironically, I found it rather disjointed and difficult to read. The editorial started talking about the ‘medical interview’ which seemed like odd and slightly unsettling terminology but after the first section it was dropped and we were back to the ‘consultation’ again. However, I am in agreement about a couple of the main threads – risk communication and the consultation length. It is deeply alarming how wrong folk get it when it comes to discussions of risk. The concepts of relative risk and absolute risk are schoolboy stuff yet are systematically misused. The editorial suggests this is an educational need and a structural problem with modern consultations needing more time. There needs to be a whole scale shift in our thinking about consultation length. This is particularly the case in practices where minor illness has been diverted to nurse practitioners or the telephone. In my view, the 15-minute consultation should be the standard for GPs – and perhaps only reduced in specific circumstances such as urgent, open-access, or ‘one-problem’ surgeries.

[Curiously, this editorial references a paper yet to be published in the BJGP. Although described as ‘in press’ in the references, it is not, as far as I can see, available to view anywhere as is commonly done in other journals. As a reader this is a fairly irritating piece of BJGP time-travel. I guess within a month or two it will be of no consequence but I hope the editor doesn’t make a habit of it.]

If you haven’t gotten to it yet then the BJGP also provides a quick and dirty summary of the new NICE guideline: Management of hypertension in adults in primary care. One of the big changes is the dropping of the diuretic from first-line treatment. Diuretics are still there, way down the list of options, but the thiazides have now dropped out of favour to be replaced by the relative unknowns, chlortalidone or indapamide. The other major change is the use of ambulatory blood pressure monitoring (ABPM) as the preferred method for diagnosis. Many practices have these ’24-hour’ cuffs but they cost upwards of about £1500. That may be an unwelcome expense for some practices but the old habit of basing decisions on a handful of BPs in the surgery has been shown to be woefully inadequate.

The paper by Helsper and chums, Follow-up of mild alanine aminotransferase elevation identifies hidden hepatitis C in primary care, is something that could change a GP’s practice. It’s all too easy to bat away mild rises in LFTs – but chronic hepatitis C infection is woefully under-diagnosed (and under-treated for that matter) and if GPs are glossing over mild rises in ALT we are missing a golden opportunity to diagnosis a treatable condition. This Dutch study took anonymised lab samples that had shown a slight rise in ALT and tested them for HCV. The prevalence of chronic HCV was 1.6% and 1.2% in patients with an ALT of 50-70 IU/l and 70-100 IU/l respectively. The anonymity does mean that there is a severe limitation as effectively the denominator is missing – we don’t actually know how many of these people already knew they were HCV positive.

Interestingly, this paper raises the point that the upper limit for normal ALT may have been distorted by the pool of undiagnosed HCV. When you consider that it’s a deeply alarming suggestion; it means that people with a serious, but treatable, disease can be hidden through something as simple as the ‘normal’ limit. It’s easy to think of so-called normal limits as being sacrosanct but like anything they are, to a degree, arbitrary. GPs should test anyone with risk factors but abnormal LFTs remain an important marker to highlight a problem.

But, I digress. The bottom-line from this paper is that even if you think you know why there is a mild ALT rise make sure you have excluded HCV infection.

Patients and doctors need to be on the same side. I keep saying this, probably quite pointlessly, but it’s true; we are not each others’ enemy. If we become so, not only are we making the NHS a battleground, a horrible place for patients, and an unhappy place to work, but also an unsustainable organisation. […]